Health Insurance Glossary
We want you to know the ins-and-outs of health insurance. That's why we've built this glossary of terms because we know that although the words are English, they often have different meanings than what we know them to be. You can check for a specific term that you are curious about or read the entire glossary if you are prepared for the most fun-filled day you have ever had. Enjoy.A-C D-F G-K L-N O-Q R-T U-Z
Access is a patient's ability to obtain medical care through a health insurance plan. The ease of access is determined by the patient's location, transportation, affordability and medical care that is acceptable to the patient.
An Accident is an unintended occurence that can include injury, illness or death. Having the proper health insurance coverage is of vital importance when the unexpected occurs.
A process in which providers or healthcare organizations are evaluated to determine if they meet specified standards as determined by the institution providing approval. Accredited physicians and health insurance organizations must also maintain these standards to preserve the designation.
The Accumulation Period is a timeframe within your health insurance policy when deductible expenses are calculated. Once you have satisfied your deductible within this period of time it is exhausted for the remainder of the calendar year.
The Actual Charge is the monetary amount charged to the health insurance plan by a physician or medical provider for a medical service or procedure. The Actual Charge may vary from the Allowable Charge as a result of the physician or medical provider being a member of the health insurance plan's network, and agreeing to a predetermined negotiated rate.
An Actuary is a mathematical professional who works for an insurance company and is responsible for analyzing and calculating health insurance premiums based upon specific data.
Acupuncture is a traditional Chinese medical technique that is used to treat a condition or disease. This alternative form of medicine is provided by professional Acupuncturists. Some health insurance plans will cover alternative treatments such as Acupuncture.
Acute Care refers to the medical treatment administered, during a short period of time, by a hospital or nursing professional for specific injuries or illness to a patient.
Additional Drug Benefit List
The Additional Drug Benefit List is a list of prescription drugs commonly prescribed by physicians for long-term and on-going patients. Also called a drug maintenance list by health insurance companies.
Providing a sufficient number of healthcare providers to members in the health insurance network that meet their needs based on geographic location and specific types of providers availability.
Adjusted Community Rating (ACR)
Adjusted Community Rating allows health insurance organizations to rate members or insured's, of a class or group based more on factors than geography and family composition. All members of each class are charged the same premium. States that participate in Adjusted Community Rating do not allow changes in the health insurance rates based on health status, and members do not have to undergo medical underwriting.
Administrative Services Only (ASO) Agreement
An ASO Agreement, also known as an Administrative Services Only agreement, is a contract made by a health insurance provider or third party agreeing to provide the administrative tasks of benefits, claims and reporting for self-funded health insurance plans.
Under Administrative Supervision, the Commissioner of the state's division of insurance, or their direct appointee takes charge of the operations of the health insurance organization.
Admissions per 1000
The Admissions per 1000 term is the number of hospital admissions recorded for every 1000 members of a health insurance plan.
Admits are the number of admissions recorded that a hospital has, including inpatient and outpatient facilities.
Adverse Selection, or antiselection, is a term used to identify those seeking health insurance who have a greater than average health risk compared to those who have a less than average likelihood of risk. As the risk gets higher, premiums from health insurance providers often get higher.
The Age Change is the date, in health insurance terms, that the person's age changes. The date is not necessarily the person's birthday, but may fall between birthdays. Health insurance providers use age changes to determine rates.
Age Limits are set by health insurance providers who determine eligibilty for applicants who are applying or are renewing medical coverage. Age limits may also be applicable to dependent children on a parent's health insurance policy.
The Age/Sex Factor is a measurement used in underwriting that compares age and sex as a factor of risk to calculate health insurance premiums. A high risk of a specific group based on ages and genders equals a higher risk of medical costs.
An Agent is a licensed salesperson who is authorized by a health insurance provider to represent their services and negotiate, sell and service health insurance contracts to consumers in exchange for a commission.
Annual Benefit Amount
Annual Benefit Amount is the dollar amount that a health insurance company determines is the maximum that they will pay out for medical expenses incurred by the member or insured within one year.
Appeals Review Committee
When members have a dispute regarding the management of their health insurance benefits, or determination of coverage, they file an appeal with the Appeals Review Committee on the health insurance company.
Authorization is the health insurance companies policy for approving benefits and eligibility of an insured for medical treatment or procedures. Many times the healthcare provider or facility will contact the health insurance company prior to rendering service to verify health insurance coverage is in effect and the member is eligible to receive benefits.
Autonomy is freedom of the insured to make decisions about their health care plan and their lives. Health care providers and health insurance companies must respect the right of the insured to make these decisions.
Balance Billing occurs when an out-of-network physician is used for a medical services. The individual with the health insurance plan is billed the difference between the medical professional's fee and the amount reimbursed under their health insurance plan.
Basic Hospital Expense Insurance
Basic Hospital Expense Insurance is a type of hospital coverage that reimburses a policyowner for expenses occurred while confined in the hospital. These expenses include room and board and other miscellaneous fees.
Bed Days/1000 refers to the number of inpatient hospital days members of a health insurance plan are treated for every 1000 members insured.
Behavioral Health Care
Behavioral Health Care is the coverage for services for mental health and chemical dependency.
A Benefit is the amount payable by a health insurance company after a doctor's visit or prescription drug purchase that is covered under a health insurance provider.
A Benefit Level is the maximum amount a health insurance company will pay for a particular service as outlined in a person's health insurance plan.
A Benefit Package is a description of benefits offered by a health insurance provider for a specific health insurance plan.
Benefit Riders are add-ons to an existing health insurance policy that provide addiitonal coverage in other areas, such as dental or vision care.
Capitation is a specified compensation paid to a physician or healthcare provider in return for healthcare services for the individual with health insurace.
A Carrier is any commercial legally authorized health insurance company offering a health insurance or managed healthcare plan.
A Carry-Over Provision allows an insured individual medical expenses from the last three months of a calendar year to be carried over into the new calendar year's deductible.
Centers for Medicare and Medicaid Services
The Centers for Medicare and Medicaid Services is a federal agency within the U.S. Department of Health and Human Services that works with state governments to administer Medicare and Medicaid services. Previously known as the Health Care Financing Administration.
Certificate of Authority (COA)
The Certificate of Authority is the license that a the division of insurance in a state issues to an insurance company or health care organization which allows it to conduct business within that state.
Certificate of Coverage
A Certificate of Coverage is a detailed plan description outlining health benefits to a subscriber and their dependents. This document also states medical services that are not included.
Chemical Dependency Inpatient
A Chemical Dependency Inpatient is an inpatient service for patients who are chemically dependent on alcohol or drugs.
Chiropractic care is a medical approach specializing in the diagnosis and treatment of the musculoskeletal system of a patient.
Claim Forms are used by insured's and providers to request payment for medical services rendered under a health insurance plan. Diagnostic and treatment codes are used on the forms to describe the diagnosis of the insured and the services rendered.
The claimant is the person or entity that files the claim for payment for healthcare services rendered.
Claims Administration is the process of determining eligibility for benefits under and insured's health insurance plan, making adjustments based on negotiated rates, and submitting payment to the health care providers.
Claims Examiners, also known as claims analysts, who work for the health insurance company review all the information pertinent to the insured's claim and make a determination of benefits.
Claims Investigation is the process of obtaining all of the pertinent information to the claim to determine the amount of benefits to pay to the health care provider.
Clinical Integration facilitates the coordination of patient care across conditions, providers, setting and time in order to achieve the best level of health care.
Clinical Practice Guidelines
Clinical Practice Guidelines outline procedures to assist providers in making decisions about a patients treatment options for specific conditions.
A health insurance plan that has Closed Access stipulates that the insured must first see their primary care provider for services before being referred to additional network providers.
In a Closed Formulary only the prescription medications on a preferred list will be covered by the health insurance plan.
Closed Physician Hospital Organization (PHO)
A Physician Hospital Organization (PHO) that limits the number of health care specialists by their type of specialty.
Closed Plans require that the insureds use participating providers in the insurance companies network.
All of the providers in a Closed-Panel HMO are either direct employees of the HMO, or are members of a group that is contracted with the HMO.
Consolidated Medical Group
One individual medical practice comprised of many providers who where previously independent health care providers. These groups can be comprised of providers from a single specialty, or multiple specialties making it a convenient environment for the patient to receive health care.
The process a health care provider or health care organization must complete with the health insurance carrier to verify their competency and the status of their licenses. Each health insurance plan has a criteria which the providers must meet to ensure they are in good standing and able to provide care for the members.